Nursing Competency: Mobile
Device Use in the Rural Setting
Application of Innovation Assignment:
Nursing Informatics
Elizabeth Davidson
Wilkes University
Nursing Informatics
NSG 600
Dr. Julie Frederick
February 23, 2016
This article is being shared by Health Scholars™ with permission from the author.
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ABSTRACT
Simulation training can improve nursing staff confidence, competence, and
communication in new and unfamiliar situations. The development of unique and
creative handheld information technology solutions to enhance nursing
knowledge in the clinical setting is gaining attention and momentum. Access to
clinical educational opportunities is reduced within the healthcare environment in
rural communities due to limited educator resource availability. Mobile device
applications developed for use by nurses practicing in rural communities can
stimulate and impart knowledge, skills, and confidence as critical-thinking skills
are advanced. Traditional nursing education and competency enhancement
takes place “in seat”. Mobile device applications provide education conducted
outside the classroom and into the live environment of care. The self-paced
mobile device platform allows learners to work outside of the classroom and at
the bedside or in the clinical environment. The curriculum is focused on
improving interaction between preceptors and nurses while establishing deeper
levels of demonstrated competency and improving safe, quality patient care
outcomes. This paper discusses the creation of a standardized, interactive
nursing education and simulation training with the ability to generate an
immersive, collaborative learning encounter for preceptor/educator and nurses
on the mobile device platform.
Keywords: nursing, simulation, mobile device, competency, education
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INTRODUCTION
Simulation training can improve nursing staff confidence, competence, and
communication in new and unfamiliar situations. Mobile device, personal digital
assistant (PDA) or computer tablet technology that is embedded within the
clinical environment has the opportunity to prevent errors by augmenting
experiences through simulation (Day-Black & Merrill, 2015). Applications
developed for use via mobile devices can stimulate and impart knowledge, skills,
and confidence as critical-thinking skills are developed by nurses practicing in
rural communities. The development of unique and creative handheld information
technology solutions to enhance nursing knowledge in the clinical setting is
gaining attention and momentum.
Access to clinical educational opportunities is reduced within the healthcare
environment in rural communities due to limited educator resource availability.
Knowledge and experience enhancement is especially challenging in a rural
community setting (Ostini & Bonner, 2012). The objective of the application of
innovation assignment is the creation of standardized, interactive nursing
education and simulation training with the ability to generate an immersive,
collaborative learning encounter for preceptor and nurses on the mobile device
platform.
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BACKGROUND
Required System Improvements
Clinical experience education, including orientation, is currently provided in a
central location. Didactic classroom followed by simulation lab sessions that
adhere to scenario-based outcome objectives provide safe realistic opportunities
to learn in a non-threatening environment. Nurses are consistently challenged to
critically think while providing patient care in a dynamic healthcare environment
(Day-Black & Merrill, 2015). Nurses must deal with complex problems with
varying levels of competency and experience in a rural healthcare setting (Forfa,
2013). Opportunities for involvement in diverse clinical experiences is
challenging in the rural setting with transition from classroom to actual practice
(Ostini & Bonner, 2012). Evidence-based knowledge application enhanced by
self-directed learning is essential in the transforming healthcare environment
(Forfa, 2013). Schlairet (2012) described the use of PDAs as beneficial to
“prompt reflection and trigger important need-learning experiences”.
ESTABLISHING MOBILE DEVICE
IMPROVEMENTS
Quality Improvement Framework Method
The system identified to be improved is simulation education in the rural
healthcare setting. The evidenced based methodology chosen for problemsolving is Plan-Do-Study-Act (PDSA) for quality improvement (QI) by studying
the results of the implemented process change and refining to achieve and
sustain results (Strom, 2013). The initial step is to identify and recruit diverse
nursing team members with varying knowledge and experience. Examples of the
QI team membership includes direct care nurses (experienced and new
graduate), educator, advanced practice nurse, preceptor, and departmental
leadership (charge nurse or manager), performance improvement (PI) staff and
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information technology analyst. Dwayne Spradin, president and CEO of
InnoCentive, advocates for soliciting good problem solvers (discriminators,
observers and inquisitors, decomposers and integrators, ideators and
synthesizers, pruners and risk-takers, workers and delegators, communicators
and presenters); those who “find great pleasure in solving problems no one else
has solved” (Hayhurst, 2013). A team leader/facilitator is identified.

Plan: Current process and clinical knowledge is clarified with
questionnaires completed to obtain the voice of the customer (VOC).
Process mapping is used to ascertain scope, boundaries, step sequence,
and process flow (Schwartz, Landis, & John, 1999). Equipment is chosen
and evaluated for ease of use. Clinical application interactive scenario
simulations are ranked and prioritized for development. Goals and
outcomes are created along with performance measurements. The
application design should motivate the learner based on Attention,
Relevance, Confidence, and Satisfaction (ARCS) while promoting
knowledge (Pange & Pange, 2011). The content should be concise,
accurate, thorough, and effective for mobile device use. A balance of text,
audio, graphics, and video should be considered (Pange & Pange, 2011).
Content should begin with course overview and objectives, progressing
systematically through knowledge enhancing content that ends with a
summary, and concluding with scenario testing and evaluation. The
expected outcome of interactive mobile device simulation is a learner
motivated to apply, analyze, compose and evaluate new information with
progression to real-life clinical application (Pange & Pange, 2011).

Do: Individual competency is evaluated at the end of the application
through scenario based knowledge and critical thinking scenario
completion. Simulation scenarios for use with mobile devices are created
that include evidence-based practice knowledge, interactive clinical
practice actions that evaluate critical-thinking, and post-application
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evaluation by end-user. The outcomes and clinical use are discussed with
the preceptor (debriefing) after the mobile device application learning is
completed. Achievements and deficiencies are recognized and evaluated
under the supervision of the preceptor (Forfa, 2013). Appliance to actual
clinical situation is discussed and planned for the preceptor or other
experienced nurse to be attendance for actual hands-on patient
experience augmentation.

Study: Review is required that ascertains whether the knowledge deficits
can be appropriately addressed with the provided curriculum within the
application. Assess completion of mobile device simulation scenario
learning, debriefing sessions with preceptors, and actual performance with
patients. Performance gaps are immediately mitigated. Allow sufficient
time for the process to be implemented and tested. Complete data review
and result comparison with goals. Observe and modify the QI/PI and
modify as necessary (OSF HealthCare, 2012).

Act: Determine if revision or further if refinement cycles are required based
on outcome data management. Automatic evaluation of ambiguous
information can be flagged by the learner within embedded software for
evaluation by the preceptor/educator with changes made even as learner
progresses within the course material.
Organizational Readiness, Strengths and Barriers
The completion of a QI/PI change as an integrated approach within a “Just
Culture” environment that acknowledges that behaviors of “human error
(unintentional mistakes), risky behaviors (workarounds), and reckless behaviors
(total disregard for established policies and procedures) can be highly successful
(McGonigle & Mastrian, 2015). Change management is augmented by review of
mobile device education simulation with end-users; clearly communicating the
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burning platform to ensure a safe learning environment and enhance quality
patient outcomes.
Readily available and accessible PDA or tablet mobile devices are a necessary
requirement. A strength is that current use of electronic medical record
documentation system that spans across the continuum has provided
acceptance of the benefits of informatics tools and resources through positive
interactions and perceptions. An identified barrier is that end-user preference of
PDA (compact and portable) or tablet (easier to visualize) may create a financial
burden in ensuring the right number of mobile devices per individual preference.
Preceptors must be educated to comprehensively support mobile device
simulation application use by controlling pace, learning cues, and providing
Additional individual learning and reflection opportunities (Schlairet, 2012).
Information and stimulus overload must be prevented by preceptor situational
awareness. Preceptors and educators remain essential in creating positive
learning situations in a dynamic ever-changing healthcare environment (Sandau
& Halm, 2010). It must be cautioned to avoid decreasing healthcare costs by
reliance on mobile device learning in place of preceptors.
Information technology (IT) and educational resources are challenged with
competing priorities and increasing volume of requests for enhancements.
Limiting factors of allocation of IT and education resources could delay program
development and expansion. Executive endorsement of the QI/PI mobile device
improvement plan with resource allocation for continued use is critical for
successful project funding.
Outcome Data Management
Outcome measurements are created based on individual clinical simulation and
scenario curriculum development. Examples of applications to be installed on
mobile devices include: IV insertion, IV smart pumps, medication administration
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(Heparin and Pitocin infusions), medication safety, urinary catheter insertion,
cardiac monitoring, fetal monitoring, and APGAR scoring. These software
applications are linked for result scoring storage and completion monitoring.
Overall goals for maximum use of mobile devices, improvements in clinical nurse
best practice competency, and patient outcomes are identified and measured.
Evaluations of mobile device education and debriefings with preceptors are
completed and evaluated for effectiveness and improvements. Follow-up clinical
application with actual patient experience is evaluated. Quarterly and annual
evaluation of learners, preceptors, and mobile device application are completed.
Secure software is created to electronically track and provide analysis along with
data mining capabilities (McGonigle & Mastrian, 2015). Key performance
indicators are translated into a customized dashboard to demonstrate clinical
competencies.
Expansion of education availability for the mobile device platform is evaluated
and prioritized for creation. The overall mobile device technology simulation
package should be evaluated for “teaching strategies and content delivery, time
and pace management, interface design, and preservation of learners’ focus”
(Pange & Pange, 2011). Assessment of preceptor and educator expert modeling
that contributes to learning through actual clinical patient competency
performance provides evaluation for enriched preceptor and educator
preparation.
MOBILE DEVICE IMPROVEMENT
IMPLEMENTATION
Endorsement
Nurse Practice Council (NPC) endorsement of the mobile device platform use to
enhance nurse competency is a critical element for successful implementation.
The NPC participation in ensuring that nurses understand the educational goals
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and benefits of the mobile device application based simulation program is
essential (Pange & Pange, 2011). Personalization based on individual assessed
learning needs is a positive perspective for acceptance. Senior leadership and
nursing shared governance endorsement and support is critical for successful
implementation and ongoing program sustainment. Barriers encountered must be
recognized and removed efficiently and effectively to sustain positive momentum.
Policy Efforts
The Tiger (Technology Informatics Guiding Education Reform) Initiative focuses
attention and action on using “informatics tools, principles, theories, and
practices to enable nurses to make healthcare safer, more effective, efficient,
patient-centered, timely, and equitable” (HIMSS, 2016). The use of informatics
tools that can be integrated into day-to day clinical practice is endorsed
extensively by healthcare professional groups. The development of mobile
device informatics tools to enhance education access and nurse competency is
an innovative solution to promote learning outside the classroom and into the
clinical environment. Nursing’s influential involvement in the creating healthcare
information technology system feature and function solutions is essential for safe
quality patient care (Murphy, 2010).
CONCLUSION
Rural community nurse competency improvement can be effectively and
economically enhanced with development and implementation of e-learning
environments (Forfa, 2013). PDAs or tablets are a vital informatics technology
resource that promotes healthcare learning and enhances the provision of safe
patient care (Day-Black & Merrill, 2015). Mobile device adoption by nurses is
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rapidly evolving with transformational use in the clinical setting (McGonigle &
Mastrian, 2015). Learning and knowledge transfer enhanced by technology
provides the opportunity for maximum benefit in the clinical environment (Harden,
2005).
The self-paced mobile device platform allows learners to work outside of the
classroom and at the bedside or in the clinical environment. Traditional nursing
education and competency enhancement takes place “in seat”. Mobile device
applications provide education conducted on PDAs or tablets outside the
classroom and into the live environment of care. The curriculum is focused on
improving interaction between preceptors and nurses while establishing deeper
levels of demonstrated competency by facilitating a common language and
understanding between nurses.
Boston-Fleischhauer, Brierley, Virkstis, Young, Stewart, and Berkow (2016)
challenge nursing leaders to embrace disruptive innovation and create the space
to innovate in the transforming healthcare environment by taking calculated, not
careless risks. Empowering nurses to commit to experimentation with mobile
device simulation applications that enhance competency creates an innovative
environment that stimulates the expansion of performance improvement resulting
in safe, high-quality patient outcomes. The implementation of a standardized,
interactive nursing education and simulation training on a mobile device platform
produces a collaborative learning encounter that is not readily available in the
rural healthcare environment.
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